WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICYWC 04 06 02 B

(Ed. 12-06)

CALIFORNIA SMALL DEDUCTIBLE ENDORSEMENT

  1. This endorsement applies to the workers’ compensation insurance coverage, the employers’ liability insurance coverage and the other states insurance coverage provided in this policy.
  1. This endorsement applies between you and us. It does not affect the rights of others under the policy. Nor does it change our obligations under the policy, except as otherwise stated in this endorsement.
  1. In consideration of a reduced premium, you have agreed to reimburse us up to the deductible amounts stated in the Schedule at the end of this endorsement for all payments legally required, including allocated loss adjustment expense, which arise out of any claim or suit we defend, where you elect to include such expenses.
  1. We will remain responsible for the full payment of all claims under this policy without regard to your ability or intention to reimburse us for the deductible amounts. The contract of insurance shall be fully enforceable by your employees or their dependents against us.

Deductible – Per Accident or Employee

5.The deductible amount stated in the Schedule is the most you must reimburse us for indemnity and medical benefits and damages combined, including allocated loss adjustment expenses, if elected by you, for bodily injury to one or more employees as the result of any one accident or for disablement of one employee due to bodily injury by disease.

Effect of Deductible on Limits of Liability

6.The applicable limits of liability as respects the employers’ liability insurance coverage provided in this policy are subject to reduction by the application of the loss reimbursement amount(s) applicable to any claim for accident or disease covered by this policy. In the event of a claim, our obligation to pay is the amount available for benefits or damages that remains after the application of the specific loss reimbursement amount. The reimbursement of allocated loss adjustment expense will not affect the limits of liability.

Allocated Loss Adjustment Expenses

7.Allocated loss adjustment expense means claims expenses directly allocated by us to a particular claim. Such expense shall not include cost of investigation or the salaries and traveling expenses of our employees other than those salaried employees who perform services, which can be directly allocated to the handling of a particular claim.

Recovery From Others

8.If we recover any payments made under this policy from anyone liable for the injury, the amount we recover will be applied as follows:

(a)First, to any payments made by us in excess of the deductible amount; and

(b)Then the remainder, if any, to reduce the deductible amount reimbursed by you.

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WC 04 06 02 BWORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY

(Ed. 12-06)

Cancellation

9.We may cancel this policy for nonpayment of any deductible amounts or for failure to comply with any security-related terms of this policy. Such cancellation of this policy shall be treated in the same manner as nonpayment of premium as provided by the California Insurance Code. We will remain fully responsible for the full amount of all claims incurred prior to the effective date of cancellation.

Sole Representation

  1. The first Named Insured stated in the Information Page will act on behalf of all the named insureds with respect to:

(a)Changes to this endorsement;

(b)Obligations to receive premiums; or

(c)Giving or receiving notice of cancellation.

Your Duties and Understanding

  1. All bodily injuries by accident or disease for which you are responsible shall be promptly reported to us for adjustment and payment, regardless of their severity or cost. You further understand that all such bodily injuries and their cost shall be included in experience data used to determine the experience rating for your policy, regardless of the eligibility of such claims for full or partial reimbursement under the deductible provisions of this policy.

Other Rights and Duties

  1. All other terms of the policy, including those which govern the following items, apply irrespective of this deductible endorsement:

(a)Our right and duty to defend any claim, proceeding or suit against you; and

(b)Your duties if injury occurs.

Additional Charges

  1. Any assessments pursuant to California statute are not part of this Plan but are included in the cost of the coverage provided by the policy to which this endorsement is attached.
Schedule
  1. Deductible Amount $ ______Each Accident.

(Dollar Amount)

  1. Allocated Loss Adjustment Expenses are ______.

(“Included” or “Excluded”)

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WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICYWC 04 06 02 B

(Ed. 12-06)

  1. The Fixed Expense Charge ______be adjusted retroactively, based upon actual costs.

(“Will” or “Will Not”)

Notes:

  1. This endorsement may be used to provide deductibles to policyholders for all or part of benefits payable under the policy pursuant to California Insurance Code Section 11735(e).

2.This endorsement has been approved for use in conjunction with the California Small Deductible Plan (Advisory).

This endorsement changes the policy to which it is attached and is effective on the date issued unless otherwise stated.
(The information below is required only when this endorsement is issued subsequent to preparation of the policy.)
Endorsement Effective / Policy No. / Endorsement No.
Insured / Insurance Company
Countersigned By

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